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Dental & Oral Health RESEARCH REVIEW™

Making Education Easy Issue 5 – 2016

In this issue: Welcome to the fifth issue of Dental and Oral Health Research Review. This issue begins with a review of the latest advances in saliva-related studies in which the potential value of Saliva in the diagnosis of saliva for early diagnosis of oral and systemic diseases is discussed. A meta-analysis of analgesics for pain of disease endodontic origin concludes that NSAIDs are the agents of choice (in the absence of contraindications). Colleagues from Australia have reviewed and provided guidelines for reducing the risks associated with radiation exposure Treatment failure in in dental practices. The final issue for 2016 concludes with a report on the use of TCMs (traditional Chinese medicines) by US-residing Chinese parents and their children for oral conditions. endodontics We hope you have enjoyed Dental and Oral Health Research Review this year, and we look forward to returning Treating permanent teeth in 2017. Kind regards with deep dentine caries Dr Colleen Murray Associate Professor Jonathan Leichter NSAIDs: first-line in [email protected] [email protected] endodontic pain relief? Management of dens Saliva in the diagnosis of diseases invaginatus Authors: Zhang C-Z et al. Summary: Saliva is a hypotonic solution of salivary acini, gingival crevicular fluid and oral mucosal exudates Oral care for pregnant with multiple functions: mouth cleaning, by washing away bacteria and food debris; digestion, as salivary patients amylase catalyses the hydrolysis of starch into maltose and sometimes glucose in the mouth; antibacterial effects provided by salivary lysozymes and thiocyanate ions; and saliva secretion contains risk factors for some Hypophosphatasia in diseases by excreting or transmitting potassium iodide, lead and mercury, and viruses such as rabies, polio and HIV infection. This review summarises the latest research into saliva-related studies and discusses the potential dentistry value of saliva in the early diagnosis of oral diseases, such as dental caries and periodontal disease, as well as cancer, diabetes and other systemic disorders. An update of radiation shielding in dental settings Comment (CM): Using saliva as a diagnostic fluid has many advantages – it is simple and non-invasive to collect, convenient to store, and contains high-quality DNA. This paper discusses the concept of salivaomics, Lollipop-induced oral which encompasses genomics, transcriptomics, proteomics, metabonomics and microRNA analysis, for the early diagnoses of some oral and systemic diseases. The structures and functions of salivary bacteria have lichenoid reaction in a child been studied as potential predictive markers for caries onset. With regards to periodontal disease, an easy to use and time-efficient P. gingivalis saliva kit has been developed. Tumour-specific DNA was positive in saliva TCM use for oral conditions in 100% of patients with oral tumours. Salivary proteins have also found to be useful for pancreatic, breast, prostate and lung cancer detection. Systemic diseases that can be diagnosed from salivary biomarkers include diabetes mellitus, acute myocardial infarction, viral infections (such as hepatitis A, B and C, HIV-1, measles, mumps, rubella, dengue and human cytomegalovirus), chronic liver disease and chronic Abbreviations used in this issue renal failure. While research on saliva and the diagnosis of disease is still in its early stage, perhaps we can HIV = human immunodeficiency virus think more positively of this bodily fluid next time we are battling with a dental procedure while elbow-deep NSAID = nonsteroidal anti-inflammatory drug in saliva. RCT = randomised controlled trial TCM = traditional Chinese medicine Reference: Int J Oral Sci 2016;8(3):133–7 Abstract

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Assessment of treatment Long-term survival and vitality outcomes of permanent teeth failure in endodontic therapy following deep caries treatment with step-wise and partial- Author: Bergenholtz G caries-removal Summary: This paper considers the place of Authors: Hoefler V et al. clinical research in the field of endodontic therapy, Summary: This systematic review included nine publications utilising data from five clinical studies (two RCTs and focuses on the assessment of cases with and three observational case-series) reporting long-term survival data (2–10 years) for 426 permanent teeth persistent lesions subsequent to endodontic with deep dentine caries treated with partial caries removal (n=167) or stepwise caries removal techniques treatment. Scant data and guidelines exist for (n=259). Failures were defined as loss of pulp vitality or restorative failures following treatment. At 2 and 3 years, assessing the failure of endodontic therapy. The successful rates exceeded 88% with both techniques. In observational data, pulp vitality was maintained in 96% paper explains that persistent apical periodontitis of teeth at 2 years with both techniques, while one RCT reported significantly higher vitality at 3 years for partial is not often regarded as a condition that requires caries removal compared with stepwise caries removal techniques (96% vs. 83%; p<0.05). Risk of bias was high treatment in clinical practice. The authors call for in all studies, due to limited quality of the evidence and methodology. comprehensive research into the effect of apical periodontitis on general health and to confirm the Comment (CM): Both stepwise and partial caries removal techniques are reported to result in fewer extent to which persisting lesions in root-filled teeth pulpal exposures than traditional one-step total caries removal. Stepwise caries removal initially removes result in adverse systemic health effects. all superficial and most of the central caries, leaving a thin layer of infected dentine to protect the pulp, placement of a provisional restoration, followed by re-entry after a prespecified time. Residual caries is then Comment (CM): Recent technological removed and a permanent restoration placed. In partial caries removal, also known as incomplete caries advancements have made root canal therapy removal or indirect pulp capping, peripheral caries is removed, the thin layer of carious dentine covering the a feasible and attractive discipline that allows pulp is retained, covered with a liner, and a definitive restoration placed. This systematic review investigated dentists to properly manage most teeth with two outcomes, namely restorative failures and loss of pulp vitality. Five studies met the inclusion criteria. endodontic complications. While endodontic Although it was found that success was greater than 88% at 2 and 3 years using either stepwise or partial success has been defined, treatment failure caries removal, the authors concluded that larger, long-term clinical studies following diverse populations has not. Is an asymptomatic tooth with apical of participants are needed. periodontitis a failure? Does a small radiographic lesion that does not change in size indicate Reference: J Dent 2016;54:25–32 success? Cone-beam computed tomography is Abstract better able to identify periapical inflammatory lesions than intraoral radiographs, showing not just small but even large lesions that had Evidence-based recommendations for analgesic efficacy to failed to be visible by intraoral radiography. treat pain of endodontic origin While this is of interest, it does not help us in clinical practice. No universal guidelines Authors: Aminoshariae A et al. exist to support clinical decision-making as to Summary: These researchers systematically reviewed English-language articles focusing on pain of which cases need retreatment and which can endodontic origin and analgesics used to decrease that pain. All papers were published between January 1990 be monitored. Clinicians and scientists have and April 2016. The aim of this investigation was to provide the best available scientific evidence for dental different perspectives with a persistent apical clinicians wanting to recommend or prescribe analgesics for endodontic pain. periodontitis being a proper and well-defined parameter in scientific investigations, but not Comment (CM): While analgesic efficacy in dentistry has historically been investigated using extraction always being regarded as needing retreatment of impacted third molars as a viable pain model, these patients differ from those in need of endodontic in clinical practice. The authors suggest that treatment who are generally older with possibly more complicated medical histories and can have long-term prospective studies on the effect of preoperative pulpal or periradicular infections. This systematic review analysed 27 randomised, placebo- periapical periodontitis on general health are controlled trials and focussed on orally administered analgesics in two primary clinical situations. The needed. In the meantime, we will have to live twelve studies reporting on preoperative analgesics showed that preoperative steroids significantly reduce with insufficient scientific knowledge and base post procedural pain and that the combination of flurbiprofen and tramadol was better than either drug our decisions on our personal interpretations. alone. Mixed reports were found regarding preoperative NSAIDs alone. Fifteen studies were included in the postoperative analgesic administration group. Most reported that NSAIDs were effective in reducing Reference: J Oral Rehabil 2016;43(10):753–8 postoperative pain. Steroids were effective particularly where there was non-necrotic pulpal tissue, i.e. Abstract either vital or irreversible pulpitis. We must, of course, remember that postoperative pain after obturation is less after complete cleaning and shaping. The availability of effective analgesics does not lessen our responsibility to do a good job!

Reference: J Am Dent Assoc 2016;147(10):826–39 Subscribe at no Abstract cost to any Independent Content: The selection of articles and writing of summaries and commentary in this publication is Research Review completely independent of the advertisers/sponsors and their products. UAE health professionals can subscribe Privacy Policy: Research Review will record your email details on a secure database and will not release them to to or download previous editions of anyone without your prior approval. Research Review and you have the right to inspect, update or delete your details Research Review publications at at any time. www.researchreview.ae Disclaimer: This publication is not intended as a replacement for regular medical education but to aassist in the process. The reviews are a summarised interpretation of the published study and reflect the opinion of the writer rather than those of the research group or scientific journal. It is suggested readers review the full trial data before forming a final conclusion on its merits. Research Review publications are intended for UAE health professionals.

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Dens invaginatus: diagnosis and management Hypophosphatasia: diagnosis and strategies clinical signs – a dental surgeon Authors: Gallacher A et al. perspective Summary: This paper reviews the aetiology and classification of dens invaginatus lesions, Author: Bloch-Zupan A a condition that predisposes teeth to developing pulpal disease. The resulting endodontic Summary: This nonsystematic review of publications on management can be challenging, due to the altered and sometimes complex anatomy hypophosphatasia described its different forms, its characteristic of affected teeth. Early diagnosis is essential, as prophylactic treatment of the dens can symptoms and associated laboratory findings. The author noted that prevent degeneration and pulpal necrosis. The article discusses the clinical features that diagnosing hypophosphatasia is challenging, as it is rare and presents assist with early diagnosis and it provides a comprehensive account of treatment options with a variety of symptoms. While a low alkaline phosphatase level and management strategies for dens invaginatus. is indicative of hypophosphatasia, reference ranges vary according to age and sex. The article defined key features of hypophosphatasia Comment (CM): Dens invaginatus, a developmental dental anomaly where an and discussed its management strategies, in particular enzyme infolding of enamel into dentine results in a pocket of organic material underneath the replacement therapy. A patient registry to better define the prevalence enamel surface, can lead to early caries and consequent pulp death. The teeth most of hypophosphatasia and raise its awareness was also described. commonly affected are lateral incisors followed by maxillary central incisors. In rare cases, dens invaginatus lesions have been reported in multiple teeth. Clinical features Comment (JL): Hypophosphatasia is a rare genetic disorder with include a pronounced talon cusp, incisal notching, and an abnormally shaped tooth autosomal dominant and autosomal recessive inheritance. Six clinical (wider mesially/distally or labially/lingually or conical in shape). A periapical radiograph forms, related to the age at which the onset of symptoms occurs, should be taken to exclude the possibility of an underlying invagination and to visualise have been described. Four of these (infantile, childhood, adult and the anatomy of the root canal system, which in dens invaginatus cases may be grossly odontohypophosphatasia) have associated dental manifestations, distorted. Patients with undiagnosed dens invaginatus may also present with symptoms with the premature loss of primary teeth with intact roots a common of irreversible pulpitis or apical periodontitis with no obvious history of trauma or key feature. The adult variant, which manifests in middle age, also caries. Dens invaginatus has been reported to affect 0.3% to 10% of the population. involves early loss of permanent teeth and an abnormal dentition. It is important to be aware of its varied presentations, always check the contralateral Odontohypophosphatasia is limited to dental manifestations and tooth as dens invaginatus is bilateral in 43% of cases, and refer to an endodontist as can occur at any age. Early exfoliation of incisors, reduced dentine treatment can be extremely complex. thickness, enlarged pulp chambers and alveolar bone loss are all key features, but no skeletal abnormalities are evident. The Reference: Br Dent J 2016;221(7):383–7 authors suggest that a question regarding early loss of primary Abstract teeth should be part of our medical/dental history questionnaires for patients of all ages. Dental health professionals can be one Oral care for pregnant patients: a survey of dental of the first healthcare professionals in a position to recognise the diagnosis of hypophosphatasia. If suspected, referral to the patient’s hygienists’ knowledge, attitudes and practice general practitioner or paediatrician is indicated. This paper aimed Authors: Schramm SA et al. to raise awareness and aid in the recognition and management of Summary: These researchers conducted an anonymous electronic survey of 1047 hypophosphatasia. I would recommend it as a worthwhile read. Michigan Dental Hygiene Association members regarding dental hygienists’ knowledge, behaviours and attitudes towards oral care for pregnant patients; there were 150 responses Reference: Int J Paediatr Dent 2016;26(6):426–38 (14%). Most respondents (64%) indicated that, regardless of their years of experience or Abstract level of degree, they would like more education about caring for pregnant patients. A willingness to provide care for pregnant patients was reported by 90% of respondents, and 85% reported that they or their employers would accept referrals to treat pregnant CLICK HERE to update your subscription women. Regarding the provision of treatments throughout pregnancy, 95.8%, 92.7%, 76.3% and 61.5% of respondents indicated that prophylactic therapies, emergency care, periodontal treatment and restorative care, respectively, were acceptable. The question “dental hygiene services should only be provided during the second trimester” had a disagreement rate of 85.6%, indicating that the level of knowledge on this topic was high. Independent commentary Comment (JL): Dental hygienists are well positioned to provide both oral care by Colleen Murray and pregnancy-related oral health information, as well as to facilitate referrals to other healthcare providers. In this anonymous electronic survey of Michigan dental Dr Colleen Murray graduated from the University hygienists, 90% of respondents were willing to provide care for pregnant women. of Pretoria with a BChD in 1984, followed Those who were unwilling cited liability concerns, not feeling comfortable or preferring by an Honours degree in Oral Radiology and not to treat them. Although high percentages were knowledgeable regarding the Diagnostics in 1987. After a combination of provision of oral care during pregnancy and the association between poor dental care private practice and university teaching, she emigrated to New and adverse outcomes/obstetric complications, inconsistencies existed regarding Zealand in 1992, took a break from dentistry and obtained her BEd when and what procedures can be safely performed during pregnancy. Only 50.5% degree. She has been in Dunedin since 2003 when the pull back to agreed that radiographs during pregnancy are safe. Most desired more education dentistry resulted in a BDS and return to private practice. This was about caring for pregnant patients. As improving health practices and preventive followed by a change to the academic setting and a PGDipClinDent behaviours of pregnant women through education and referrals could reduce the risk in Paediatric Dentistry. Colleen is currently a Senior Lecturer in the of premature births and low birthweight babies, it is important that we are all able to Department of Oral Rehabilitation at the University of Otago, Pacific provide this service. If our knowledge or attitudes need to be updated, reading this Island student support officer for the Faculty, NZDREX examiner and paper may provide the necessary motivation. is on the ANZSPD committee. This is interspersed with her own research projects, particularly in the area of Dental Education, as Reference: J Dent Hyg 2016;90(2):121–7 well as student research supervision. Abstract

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Radiation shielding in Lollipop-induced oral lichenoid reaction in a child dentistry: an update Authors: Bastos DB et al. Authors: Crane GD & Abbott PV Summary: These authors reported the unusual case of a 15-year-old girl who had white plaques on her tongue Summary: These authors performed a literature and buccal mucosa that were initially diagnosed as oral lichen planus; systemic or local medication use was review and compiled guidelines on radiation denied by the patient and her parents. Biopsy findings were suggestive of oral lichen planus. Her lesions did protection for dental patients. Few published not respond to topical corticosteroids. Further investigations revealed almost daily consumption of an artificially data exist on the effects of low-dose radiation coloured and flavoured lollipop. She stopped consuming these lollipops, and 1 week later her oral lesions had used in dental practice, and most risk models completely resolved. A diagnosis of an oral lichenoid reaction was made. are extrapolated from higher dose models. The Comment (JL): Oral lichen planus, an autoimmune, mucocutaneous disease that affects the oral authors caution that this “lack of evidence does mucosa, usually affects middle-aged females. Oral lichenoid reactions are clinical and histological , noting no ‘safe’ not denote the absence of risk” contemporaries of the classic oral lichen planus and are often associated with an identifiable inciting level of radiation exposure has been established factor. In children, the diagnosis of oral lichenoid reaction is challenging due to nonspecific findings, its and all imaging utilising ionising radiation poses rarity in this group, as well as communication difficulties. This clinical report describes a 15-year-old a potential risk for patients. As such, the benefits female who reported with bilateral white plaques on her buccal and tongue mucosa. A biopsy was taken of imaging must outweigh such potential risks, with the histopathological diagnosis suggestive of oral lichen planus. It was only at the third clinical and all diagnostic imaging should adhere to the interview that the patient’s habit of sucking artificially coloured and flavoured lollipops was discovered three basic principles of justification, optimisation – a behaviour unknown to her parents. These lollipops contained several compounds that could have and application of dose limits. Dose reduction induced the oral lichenoid reaction. This paper highlights the importance of a thorough medical history techniques and shielding of sensitive organs were and investigation of a patient’s habits, and the possible need to keep asking questions. Patients may discussed, as was imaging in pregnant patients. assume that some information is not relevant and therefore neglect to mention it, and parents do not Comment (JL): Both the National Protection always know everything their children are doing. Board and the International Commission on Reference: Int J Paediatr Dent 2016;26(6):486–9 Radiation Protection support that there is no Abstract threshold dose below which radiation is safe, and exposure of any tissue has the potential to induce malignant change. The thyroid gland Utilization of Chinese herbal medicine for selected oral is of the greatest concern in dental imaging, particularly in young patients. In a 6-year old, conditions in two pediatric populations it lies 20–30mm closer to the dentition than Authors: Dai MR et al. in a 16-year old. Although prospective data Summary: In this research, 318 Chinese parents with children aged <12 years were interviewed regarding on thyroid cancer risk and common diagnostic the use of TCM for oral conditions by themselves and their children. TCM use for oral conditions was reported radiographs are limited, use of a thyroid by 45.6% of the respondents (parents), with 19.1% reporting their children also used TCM for oral conditions, shield/collar, the paralleling technique and mostly aphthous ulcers (64.2%). The most frequently used TCMs were watermelon frost (37.4%), niuhuang rectangular collimation is strongly advised, jiedu pian (15.5%) and honey/propolis (9.9%). Significant predictors of TCM use included duration of US especially for those under the age of 20 years. residency, with birth location and parental TCM use associated with childhood use. As lead aprons do not protect against scattered internal radiation or provide a difference in the Comment (JL): TCM, practiced for thousands of years, includes herbal medicines, acupuncture, massage, extremely low gonadal zone, their use is not exercise and dietary therapy, and is accepted in many parts of the Western world as part of complementary indicated for dental imaging other than to allay or alternative medicine. As TCM is used for both adults and children, it is important that we are familiar with patients’ anxieties or concerns. In pregnancy, the common Chinese medicines used for oral conditions such as halitosis, gingivitis/periodontitis, aphthous use of a lead apron is indicated only when ulcers, herpes labialis and toothache. This study, which explored the use of TCM for oral conditions in two the primary beam is positioned towards the Chinese paediatric populations, found that 19.1% of children younger than 12 years of age had used TCM patient’s trunk, e.g. in an occlusal maxillary at least once during the previous 2 years. Participants in this study felt that TCM agents were effective with view. Any individuals in the room during few adverse reactions. It is important that, when we go over our patient’s medical histories, we remember radiographic exposure, such as a parent, must to include questions about the use of medicines other than those prescribed or bought from a pharmacy or wear a lead apron. While radiology in dentistry supermarket. While some Chinese herbal medicines are safe, others may cause side effects or react with has significant diagnostic benefits, always other drugs. Knowledge of the ingredients of common TCM agents is advised, particularly as we work and keep in mind that the benefits for the patient live in a diverse cultural environment. must outweigh the potential risks. Reference: Pediatr Dent 2016;38(4):311–6 Reference: Aust Dent J 2016;61(3):277–81 Abstract Abstract

Independent commentary by Jonathan Leichter DMD, Cert Perio (Harvard). Subscribe at no cost to any Research Review Associate Professor Jonathan Leichter is currently Senior Lecturer in the Department of Oral Sciences at the University of Otago. Associate Professor Leichter joined the faculty after UAE health professionals can subscribe to or 20 years in fulltime private practice in New York and Boston, 18 of which were spent in download previous editions of Research Review specialist practice limited to periodontology and implant dentistry. Trained at Tufts University publications at www.researchreview.ae and obtaining his specialist training at Harvard University, he has been actively involved in clinical dental implant practice since 1984. Since 2002, he has supervised and mentored postgraduate students in periodontology, endodontics and prosthodontics. His research interests and publications are in the field of periodontology, dental trauma and laser applications in dentistry.